Essential hypertension

Essential hypertension

1. OPTOM FASLU MUHAMMED
.

2. What is Hypertension
Hypertension is also referred to as high blood
pressure or high BP in common terms
It is a medical condition in which the arterial
blood pressure is elevated.
It is termed as silent killer – Patients
asymptomatic - leads to fatal complications

3. Definition
Greater than 140 mm hg of systolic blood pressure
and
or
more than 90 mm hg of diastolic blood pressure
at least on 2 of 3 occasions while measuring the
pressure.

4. 1. How to measure
blood pressure?

5. Nokolai Korotkoff, 1905
Ascultatory method of
blood pressure measurement

6. How to measure Blood pressure???
Always measure B.P when the patient is completely
relaxed.
The instrument used is mercury
sphygmomanometer .
The cuff of the apparatus should cover up to three –
fourth of his arm.

7. How to measure Blood
pressure???
The tubings must be parallel to arteries of the arm.
You must then inflate it until there is radial pulse
depression.
Then deflate and measure the value.
The sound as korotkoff sound
Details in the video link and audio link
http://www.youtube.com/watch?v=u6saTO8_o2g&feature=related
http://www.thinklabsmedical.com/stethoscope_community/Sound_Library

8. Terms
What is Systolic blood pressure- upper limit of
the pressure at which korotko’s sounds start
appearing ---state of contraction in heart.
Diastolic blood pressure is the lower limit of
sounds heard - state of relaxation in peripheral
blood vessels.

9. Normative values
Systolic-90 mm hg – 120 mm hg.
Diastolic-60 mm hg -80 mm hg.

10. JNC classification
Systolicdiastolic interpretation
Less than 120
mm Hg
Less than 80
mm Hg
Normal
120 to 139 80 to 89 Pre hypertensive
140 to 159 90 to 99 Stage 1 Hypertension
More than or
equal to 160
More than or
equal to 100
Stage 2 Hypertension
> 220 > 120 Hypertensive emergency
Source: Joint national committee on cardiovascular diseases 2003

11. Nearly 1 in 3 adults (31%) in the US has hypertension
Fields LE et al. Hypertension. 2004;44:398-404.
Hypertension:
How Big Is the Problem?
At Least 65 Million Americans Require
Treatment for Hypertension

12. Magnitude of problem in India
Prevalence 1 in 3 in urban population among 40 yrs or
more
More than 50% among persons aged 65 or more
India is the capital of Diabetes Mellitus and the
associated HT is > 60%
The prevalence increasing with years

13. Types of Hypertension
The most common cause for Hypertension is
idiopathic and hence if the cause is not known it is
called as primary or essential Hypertension--90%
If it is secondary to other diseases -it is called as
secondary hypertension.-10%

14. Pathophysiology
The main reason is vasoconstriction which occurs due
to sympathetic over-activity
An overactive renin – angiotensin system leads to
vasoconstriction and retention of sodium and water.

15. ESSENTIAL HTN
Benign(chronic)
Rise in B.P is slight to moderate
Complications: heart failure, cerebrovascular accident
or MI
Risk factors

16. Malignant (accelerated)
Rapid & aggressive acceleration
Diastolic pressure in excess of 120 mmHg
Eg: haemorrhages into the retina, pappillo-edema &
progressive renal disease- cardiac failure

17. SECONDARY(ACCELERATED)
Kidney disease: retention of salt and water
Endocrine disorders:
Secretion of excess aldosterone and cortisol
stimulates the retention of excess sodium & water by
the kidneys, raising the Blood volume & pressure

18. Endocrine causes
 Acromegaly - increased secretion of growth
hormone in adults.
Cushings syndrome – increased secretion of
steroid hormone in children and adults .
Pheochromocytoma - tumor of adrenal medulla.
Drug such as corticosteroid and hormones like
estrogen.

19. Renal causes of Hypertension
Glomerulo nephritis-- acute or chronic or / and infective
or non infective.
. Bacterial infection of kidney-chronic pylo-nephritis.
. Polycystic kidney disease – It is a genetic cystic disorder of the
kidney.
Apart from these any renal disease which can cause renal
failure like Diabetes Mellitus will result in secondary hyper
tension.

21. Risk factors
Primary hypertension
Age (older the risk is higher)
Diet (High salt intake/ fatty diet)
Physical activity (sedentary life style)
Alcohol >15ml /day
Obesity----BMI>30
Drugs (steroids, oral contraceptives)
Stress - Chronic job stress
Family history—overcrowding
Ethnic groups- black africans
Males

22. Diagnosis of Hypertension
The gold standard for hypertension is only clinical
measurement using mercury sphygmomanometer
But we need to do investigations to rule out
secondary causes
Better to screen everyone above 40 years every year
and every six months if there is a risk factor

23. Hypertensive at first visit
In the first measurement if there is >220 mm hg of
systolic pressure and >120 mm hg of diastolic pressure
then we can call the patient as hypertensive - an
emergency.

24. Symptoms
No specific symptoms in majority.
weakness
Sub-occipital headache
Restlessness.
Sleepiness.
Dizziness.
Epistaxis– nose bleed

25. TIA = transient ischemic attack; LVH = left ventricular
hypertrophy; CHD = coronary heart disease;
HF = heart failure.
Retinopathy
Renal failure
Peripheral vascular disease
Complications of Hypertension:
LVH, CHD, HF
TIA, stroke
Hypertension Hypertension
is a risk factoris a risk factor

26. Complications
•Myocardial infarction (Heart attack) or
coronary artery disease
•Cerebro vascular accident / stroke
•Left ventricular hypertrophy causes cardiac
failure
•Renal failure
•Hypertensive Retinopathy

27. Investigations
•We have to rule out secondary hypertension by
investigating for other diseases.
•Renal – urine microscopy is done to detect the
presence of albumin.
•Presence of RBC, Cast is an indications of
glomerulo- nephritis.
•Excess of WBC indicates kidney infection.
•Renal doppler / technicium scan (nuclear scan) is
done to know about blood supply to the kidney.

29. Most patients will experience better control if they
modify diet and exercise.
Physician advice sometimes works and should
always be given along with a follow-up visit
appointment to monitor both blood pressure and
lifestyle change efforts.
Most of us do not do lifestyle counseling beyond
simple advice and admonishment – the time factor
is a problem.
Nevertheless, lifestyle modification is at the top of
medical management.

30. Modification
Approximate SBP
reduction (range)
Weight reduction 5-20 mmHg / 10 kg
weight loss
Adopt DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity 4-9 mmHg
Moderation of alcohol
consumption
2-4 mmHg
Benefits of Lifestyle Modification

31. Management of patients
•Diet
• Use <5 gms of salt per day
• Avoid oily food / fatty diet
• Low calorie high fiber diet
•Exercise
• Brisk walking, jogging, Swimming etc…
Avoid smoking & alcohol.

32. Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
TROPHY Study ACC 2006: Even lowering BP in those with pre-HTN appears
to reduce incidence of new HTN by up to 60%

33. Drugs For Hypertension
•Usually divided into 4 categories:
• Diuretics
•ACE (Angiotensin converting enzyme) inhibitors and AT
receptor blockers
• Beta blockers
• CCB (calcium channel blockers)
• vasodilators

34. ACE inhibitors
Blocks the conversion of Angiotensin to Renin by inhibiting
angiotensin converting enzyme Eg: Enalapril , Lisinopril.
•Side effects
• Produce dry cough
•Altered taste sensations (dysguesia)

35. AT receptors blocker
•More potent than ACE inhibitors - it blocks the
receptors on which enzymes will act Eg :
Losartan

36. Beta blockers
Beta 1:cardiac selective ( Eg: Atenolol )
Non cardiac selective beta blockers
( Eg:Timolol, Propanalol).
Beta blockers with intrinsic
sympathomimetic activity.

37. Beta Blockers
•Mechanism of action:
• Acts on the beta adrenergic receptors.
Side effects:
• Can precipitate asthma in asthmatics-Beta
receptors are present on the bronchus causing broncho
constriction.
• Decreases the cardiac output as well as the heart
rate.
• Can increase the cholesterol level.
• Can mask hypoglycemia in diabetics

38. Calcium channel blockers(CCB)
Allows peripheral vaso dilatation
Causes decrease in the peripheral vascular
resistance
Very safe during pregnancy
 Eg: Nifidepine, Amlodepine.
Side effect: Postural hypotension, Headache,
Edema, Tachycardia

39. Other drugs
• Diuretics Eg: Thiazide diuretics, Hydro chlor
thiazide
•Alpha blockers: Prazosin
•Vasodilators: Hydralazine and sodium nitroprusside
•Centrally acting drugs: Methyldopa, Arkamine

40. Management of Hypertension
•Depends upon the blood pressure
•If person is pre-hypertensive or stage 1 is – life
style modification should be done first.
•Diet and exercises are first modes to control
mild hypertension
•If Blood pressure is high – Polypharmacy 3 or 4
drugs can be given.

41. Some guidelines for drugs
•If the patient has
•Renal problem – ACE inhibitors
•Diabetes mellitus – ACE inhibitors
•Asthma – ACE inhibitors
•Diabetic / pregnancy – CCB
•Anxiety /hyperthyroidism – Beta blockers

42. Hypertensive emergencies
•They may result in end organ damage e,g., Kidney
retina
•Blood pressure should be reduced fast to prevent
end organ damage. Drugs commonly used are:
•Alpha blockers –Prazosin
•Vasodilators – Sodium nitroprusside / Nitrates
•Alpha + beta blockers – Labatelol
•CCB - Nifedepine

43. Barriers to Controlling
Hypertension
Healthcare
System
Patients Providers

44. The Initial Confrontation of the HTN
Problem
Upon making a diagnosis of HTN, tell patient
the BP reading and what it should be (provide a
written copy).
Prepare patient for the probable necessity for
polypharmacy to control BP with a minimum
of side effects
Advise Home BP measurement (135/85
mmHg is considered to be hypertensive).
Table 28. JNC 7 Report. Hypertension. 2003;42(6):1240.

45. Self-Measurement of BP
Provides information useful for:
1.assessing response to antihypertensive Rx
2.improving adherence with therapy
3.evaluating white-coat HTN
Home BP is more strongly related to target
organ damage and has better prognostic
accuracy than office BP.

46. Thank you for your
patience